ACT is designed to speed you through the Contracting process at

ACT is designed to speed you through the Contracting process at ACA. 1. Fill in the ACT Appointment Data Sheet 2. Sign the Authorization To Execute 3. Sign the Efficient Forms Signature Authorization We Will Do The Rest! ACT APPOINTMENT DATA SHEET Instructions Please print clearly when completing the ACT Appointment Data Sheet. Fill in all applicable General Information, Contact Numbers, License Information, and Banking Information. All Personal History questions must be answered and details must be provided for all Yes answers. Sign and date the Certification at the bottom. Read the Authorization To Execute Contract Documents On My Behalf. Check the box indicating you have read and understand the Authorization. Date and sign the authorization including Corporate Entity name, if applicable. Return the ACT Appointment Date Sheet (2 pages) and the Authorization To Execute Contract Documents On My Behalf and the Efficient Forms signature page to an ACA Representative for Processing. You will have access to electronic copies of all the ACA Documents, including Insurers documents, completed and executed by ACA designees on your behalf. You will be notified by email that such access is available. You should promptly review the documents and advise ACA by letter or email if there are any errors in any of them, or if you have any objection to any part of them. You understand that you will be legally bound by such documents once they are accepted by ACA and by the respective insurers. *Agent Contracting Technologies RETAIN FOR YOUR RECORDS ACAADSI032011(rev.072011) 1 of 6

PROCEED TO PAGE 3 IMPORTANT INSTRUCTIONS Since the ACT process prepares and submits all of your contracting to the carriers, review each contract submitted to the carriers (Life of the Southwest/National Life Group, Americo, and Mutual of Omaha) by following the steps below. To Access Life of the Southwest/National Life Group contract: 1. Log on to www.aclassic.com 2. Click on Join Us on the left side of the Home Page 3. Click on Online Producer Contracting Application under the National Life and LSW heading 4. You will be directed to nomoreforms website. Scroll down to the Returning Applicant section 5. Enter your social security number 6. Your password is aclassic ( the password is case sensitive) 7. Your package code will be provided by the BaseShop Manager (the package code is case sensitive) 8. Click Logon To Nomoreforms 9. Choose any of the contract documents by clicking on the form name. When the form opens, you have the option to print the document. 10. Click the back button on your web browser to return to the list of forms and view/print all forms that you would like to have. 11. After viewing/printing the last document, return to the list of forms, scroll down and click on Return to NMF Logon to exit nomoreforms. To Access Americo and Mutual of Omaha Contracts: 1. Log onto www.aclassic.com 2. Click Join Us on the left side of the Home Page 3. Click on Online Producer Contracting Application under the Mutual of Omaha and Americo heading 4. You will be directed to the Efficient Contracting Solution website 5. Your User ID is the first initial of your first name followed by your last name followed by the last 4 digits of your social security number (no spaces). For example, John Smith with 7890 last four digits would have the User ID jsmith7890. 6. Your Password is aclassic 7. Click Sign In 8. Click on View Contract Requests 9. Select the Contract you would like to view/print by clicking on the circle to the left of the carrier name 10. Click on Work With A Single Carrier Contract Request 11. Click on View/Print Forms 12. The contract will open in a new web browser box. When the contract opens you may view/print it from the toolbar. 13. When finished with that contract, close that web browser box. You will see an American Classic Agency page with one button. Click on Return To Appointment Detail. 14. Click on Return 15. Repeat steps 9 through 14 for each contract you wish to view/print. 16. When finished with all contracts, click on Return To Agent Menu. 17. Click on Log Out. RETAIN FOR YOUR RECORDS ACAADSI032011(rev.072011) 2 of 6

ACT APPOINTMENT DATA SHEET GENERAL INFORMATION (Please print clearly) Your ACA Recruiter s Name: Name: First Middle Last Social Security Number: Are you a United States Citizen: Yes No Date of Birth: / / (MM/DD/YYYY) Gender: M F Drivers License Yes No #: State: Email Address: Send Mail To: Business Address Residence Residence: (if you use a PO Box indicate a street address for overnight delivery) Address: County: Business: City, State, Zip Code: Address: City, State, Zip Code: Month & Year Moved To Residence: / County: Broker Dealer Affiliation: CRD #: Broker Dealer Name: CONTACT NUMBERS Residence Number ( ) Business Number ( ) Cell Number ( ) Fax Number ( ) PARTNERSHIP, CORPORATION, DBA INFORMATION Corporation Name: Tax ID Number: Name and titles of officers of corporate agency: LICENSE INFORMATION Are you currently licensed? Yes No Types of License: Life Health Life/Accident/Health/Variable Resident License #: Expiration Date: / / License State: BANKING INFORMATION Commissions Payable to: Individual Corporation EFT is required in order to pay commissions in a timely manner. I authorize commissions to be deposited into my Savings Checking account. I also authorize debits to this account for deposits made in error. Name of Financial Institution Transit ABA Account Number ACAADS022011(rev.07/11) 3 of 6 Submit via email to acacontracting@aclassic.com or fax (904)285 3443

ACT APPOINTMENT DATA SHEET PERSONAL HISTORY If you answer yes to any of the questions below, please explain in the section provided below. 1. Do you have Errors & Omissions Insurance? Yes No Name of E&O Carrier and amount of coverage 2. Have you moved in the last 5 years? If,so list prior addresses below(include county): Yes No 3. Has any claim ever been made against you, your surety company, or errors and omissions insurer Yes No arising out of insurance securities sales or practices, or have you been refused surety bonding? 4. Have you ever been convicted, pled guilty, pled no contest, had charges dismissed through a first time offender Yes No program for any offense, misdemeanor (other than minor traffic violations) or felony charges; or are you under indictment or have charges currently pending against you or a business with which you are connected? 5. Do you currently have a pending bankruptcy or have you ever filed for bankruptcy, been declared Yes No bankrupt or insolvent, or had your salary garnished? Disposition: Discharged (mm/dd/yyyy) Open 6. Are you or any business entity in which you have interest at the present involved in any litigation Yes No or are there any unsatisfied judgments or liens (including state or federal tax liens) against you or any business entity in which you have interest? 7. Have you ever had a bond denied, paid out or revoked? Yes No 8. Have you ever(a) had any life or health insurance producers contract or appointment Yes No cancelled for(i)cause,(ii)lack of production,or (iii)involuntarily for any other reason, or (b) had any employment terminated for cause? (if Yes, please explain) 9. Are you indebted to any Insurance Company/Agency Manager? (including debit balance) Yes No 10. a.)have you, or any business entity in which you have an interest, ever been, or do you Yes No anticipate yourself or any such entity being (i) investigated, fined, suspended, placed on probation, or reprimanded by any insurance department, the SEC, or any other regulatory authority; (ii) entering into a consent order with any insurance department, the SEC, or any other regulatory authority; (iii) having an insurance, securities or other professional license or registration refused, suspended, restricted or revoked; or b) are you, or any such business entity currently under investigation by any insurance department, FINRA, the SEC, or any other regulatory authority? 11. Have you ever held a license in (or been known by) another name? (please explain and provide dates) Yes No 12. Do you currently sell in the Hispanic market and/or do you currently sell Retirement planning products? Yes No 13. Are you currently or have you ever been contracted/affiliated/appointed with National Life, Life Insurance Company of the Southwest or Equity Services, Inc.? Americo? Mutual of Omaha? Yes No 14. Do you have any affiliation with a Bank? Yes No 15. Have you completed AML Anti Money Laundering? Yes No If you answered yes to any of the above questions, please explain: CERTIFICATION: I certify that the information contained in the ACT Appointment Data Sheet is true, accurate, and complete, to the best of my knowledge and belief. I understand that if any of the information I have furnished is incorrect or incomplete it may be the basis of rejecting me as an agent or terminating any contracts which have been entered into on the basis of the incorrect or incomplete information. SIGNATURE: Entering my name below constitutes my electronic signature, and is intended by me to have legally binding effect. Your Signature: Date: / / Print Name: ACAADS022011 4 of 6 Submit via email to acacontracting@aclassic.com or fax (904)285 3443

AUTHORIZATION TO EXECUTE CONTRACT DOCUMENTS ON MY BEHALF 1. I wish to become contracted and/or appointed with American Classic Agency, Corp. ( ACA ), and the life insurance companies ( the ACA Carriers) listed in paragraph 3, below, for which it is a marketing organization. I have filled out and electronically signed and submitted an ACT Appointment Data Sheet containing information required to complete the documents listed in paragraphs 2 and below (collectively the Contract Documents) and to determine whether I qualify for appointment by the ACA Carriers. I understand that all such contracts and appointments are subject to the approval of ACA and the applicable ACA Carriers, to ACA s execution of the ACA Documents (defined below) and to my appointment by the applicable ACA Carriers. 2. In order to be contracted with ACA, I have to execute the following documents, in addition to the ACA Data Sheet I have already electronically executed ( the ACA Documents ): Sales Representative Agreement, ACA Security Agreement. 3. In order to be contracted with and appointed by each of the following life insurance companies, I have to complete and execute the standard forms they require in order to contract or appoint an independent agent ( the Insurer Documents ): National Life Insurance Company, Life Insurance Company of the Southwest, Mutual of Omaha Insurance Company, United of Omaha Life Insurance Company, United World Life Insurance Company, Companion Life Insurance Company, Americo Financial Life and Annuity Insurance Company and Great Southern Life Insurance Company 4. I authorize an individual of ACA designated by it to, on my behalf, (i) complete each of the ACA Documents and each of the Insurer Documents on the basis of information I have provided in the ACT Appointment Data Sheet and (ii) electronically sign each of such Documents. I agree that each of such documents so completed and so signed shall be legally binding on me, just as if I had myself completed and signed it. This authorization is limited to the documents required for my initially being contracted with and/or appointed by ACA and each of the ACA Insurers, and does not extend to any subsequent changes or amendments to any of the Contract Documents or to the termination of any of them. 5. I understand that I will have access to an electronic copy of each of the ACA Documents and of each Insurer Document completed and executed by ACA on my behalf. When I am notified by email that such access is available, I will promptly use it to review such documents, and will advise ACA by letter or email if there are any errors in any of them, or if I have any objection to any part of them. I understand that I will be legally bound by such documents once they are accepted by ACA and by the respective insurers. 6. If the ACT Appointment Data Sheet indicates that the contracts and appointments are to be in the name of a corporation, partnership or other business entity, the word I in this Authorization means both the entity and the individual completing this Authorization. In such case, both the entity s name and the individual s name should be electronically signed as set forth below. Entering my name (and the name of my corporation or other entity, if any) below, following the word Signature constitutes my electronic signature and is intended by me to legally bind me to this agreement and to each of the Contract Documents which ACA completes and electronically signs on my behalf. I have read and understood the above Authorization. Date: / / Please sign in the box: Corporation Entity Name: Print Name: Submit via email to acacontracting@aclassic.com or fax (904)285 3443 ACAAEOMB0611(rev.07/2011) 5 of 6